Introduction to Health Education pdf

LECTURE NOTES For Health Extension Trainees in Ethiopia Introduction to Health Education Meseret Yazachew Yihenew Alem Jimma University In collaboration with the Ethiopia Public Healt

LECTURE NOTES

For Health Extension Trainees in Ethiopia

Introduction to Health Education

Meseret Yazachew Yihenew Alem Jimma University

In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,

the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education

Funded under USAID Cooperative Agreement No 663-A-00-00-0358-00

Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education

Important Guidelines for Printing and Photocopying

Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty All copies must retain all author credits and copyright notices included in the original document Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication

©2004 by Meseret Yazachew Yihenew Alem

All rights reserved Except as expressly provided above, no part of this publication may

be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors

This material is intended for educational use only by practicing health care workers or

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Acknowledgment

The development of this lecture note for training Health Extension workers is an arduous assignment for Dr Meseret Yazachew and

Dr Yihenew Alem at Jimma University

Essentially, it required the consolidation and merging of existing in depth training materials, examination of Health Extension Package manuals and the Curriculum

Recognizing the importance of and the need for the preparation of the lecture note for the Training of Health Extension workers THE CARTER CENTER (TCC) ETHIOPIA PUBLIC HEALTH TRAINING INITIATIVE (EPHTI) facilitated the task for Jimma University to write the lecture note in consultation with the Health Extension Coordinating Office of the Federal Ministry of Health

Finally the Federal Ministry of Health would like to express special words of gratitude for those who contributed and endeavored to the development of this lecture note and to TCC/USAID for the technical and financial support

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Table of Contents

Content Acknowledgement i

Table of content ii

List of abbreviations vi

List of tables vii

List of figures vii

Introduction ix

UNIT ONE: Introduction To Health Education Objectives 1

Health Education 3

• Historical development .3

• Definitions .4

• Aims and Basic principles of Health Education 7

• Approaches to Health Education 10

• Targets for Health Education 10

• Health Education settings 11

• Who is responsible for Health Education? 11

• Role of Health Educator 12

Exercises 13

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UNIT TWO: Health And Human Behavior

Objectives 14

Introduction 14

Definition of behavior and other related terms 15

Factors affecting human behavior 17

The role of human behavior for prevention of disease 22

Exercise 25

UNIT THREE: Working With Communities Objectives 26

Introduction 26

Definition of community 27

Concept of community participation 27

Benefit of community participation 30

Helping people to organize: The role of Health Extension Workers 31

UNIT FOUR: Health Communication Objectives 35

Introduction 35

What is communication? 36

Why communication? 36

Types of communication 37

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Components of communication 38

Communication stages 41

Common communication approaches 49

Methods of communication 49

Barriers to effective communication 51

Characteristics of effective communication 55

UNIT FIVE: Educational Methods And Materials Objectives 57

Introduction 57

Educational methods 58

• Individual 58

• Group 63

Teaching materials 77

• Audios 77

• Visual aids 79

Mass media 84

Exercise 87

UNIT SIX: Training

Objectives 88

Introduction 88

What is training? .89

Types of training 89

Phases of training 89

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Exercise 94

UNIT SEVEN: Planning, Implementation and Evaluation Of Health Education Programs Objectives 95

Introduction 95

Planning process 95

• Information gathering 97

• Defining and prioritizing problems 101

• Setting goals and objectives 103

• Identifying and obtaining resources 105

• Selecting appropriate methods 107

Carry out and evaluate the project 110

• Development and implementing a project plan 110

• Evaluating the project 111

Exercise 113

UNIT EIGHT: Ethical Issues in Health Education Objectives 114

Introduction 114

Definition 114

Basic Principles of Ethics 115

Health extension workers responsibilities as a health educator 117 Exercise 119

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Reference: 120

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List of abbreviations

AIDS Acquired Immuno-Deficiency Syndrome

HE Health Education

HEWs Health Extension Workers

BCC Behavioral Change Communication

FGM Female Genital Mutilation

FP Family Planning

HIV Human Immunodeficiency Virus

HSDP Health Sector Development Program

IEC Information Education Communication

MOH Ministry of Health

PHC Primary Health Care

WHO World Health Organization

UNICEF United Nation Children’s Fund

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List of tables

Table 4.1 Examples of failure at different communication

• stages 47

Table 5.1.Main characteristics of mass media and face-to-face communication 85

List of figures Fig.2.1 Levels of prevention of disease 22

Fig.4.1 Complete communication model 38

Fig.4.2 Communication stages 42

Fig 6.1 Project planning cycle 96

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Introduction

The impetus for writing this lecture note arose from two but interrelated pressing demands The primary reason is the identification of community based health care approach, as a strategy, by the MOH of Ethiopia which intern required the training of Health Extension Workers (HEWs) In addition to the eight components of HSDP identified during the 1st phase, HSDP II included the training and deployment of HEWs who will be delivering essential health care services at the grass root level Reference materials on health communication both as an aid for the training of these groups of development workers as well as for future utilization

at the work places are scarce or absent so far

Appreciating the critical necessity of this material, the Carter Center/ Ethiopian Public Health Training Initiative, requested Jimma University to prepare and make it ready for the purpose

Accordingly, the Department of Health Education & Behavioral Sciences made utmost effort to produce the material within the shortest time possible We tried to include major topics on health education and promotion taking into account the scope of the beneficiaries and the essentiality of some titles The first two chapters deal with the concept and principles of health education and issues related to health and human behavior With the assumption that the health extension workers are closely working with and for the community, the general concept and ways of community participation

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is described in the 3rd chapter The fourth chapter discusses on health communication

Educational methods and materials are purposely discussed relatively

in a more detail in chapter five to provide adequate alternatives for the HEW in their effort of communicating issues on disease prevention and health promotion to individuals and families at household level The 6th and 7th chapter addresses planning process

of health education programs and designing training sessions, respectively Working with the community is something to be carried out with caution Therefore, ethical issues and standards are discussed in the last chapter

The authors believe that, though this lecture note is primarily prepared for HEWs as a reference material, other paramedical and related health educators can find it useful

During the writing, we have tried our best to utilize simple and understandable terms so as to make its consumption easier at all levels Examples and illustrations from personal experiences and the work of other colleagues were used to make the material more palatable Objectives of each topic in every chapter are outlined to help readers anticipate some knowledge before going through the section Study questions are also forwarded at the end of every chapter to serve as a self-test Lastly, we would be grateful and enthusiastic to receive any sort of feedbacks and comments on the writing

UNIT ONE Introduction To Health Education

Objectives

At the end of this chapter, the trainees will be able to:

• Explain the concept of Health

• Define Health Education

• State historical development of Health Education

• Describe objectives of Health Education

• State basic principles of Health Education

Before discussing about health education, it is imperative to conceptualize what health itself means Health is a highly subjective concept Good health means different things to different people, and its meaning varies according to individual and community expectations and context Many people consider themselves healthy

if they are free of disease or disability However, people who have a disease or disability may also see themselves as being in good health

if they are able to manage their condition so that it does not impact greatly on their quality of life

WHO defined health as “a state of complete physical, mental, and

social well being and not the mere absence of disease or infirmity.”

Physical health – refers to anatomical integrity and physiological

functioning of the body To say a person is physically healthy:

• All the body parts should be there

• All of them are in their natural place and position

• None of them has any pathology

• All of them are doing their physiological functions properly

• And they work with each other harmoniously

Mental health - ability to learn and think clearly A person with good

mental health is able to handle day-to-day events and obstacles, work towards important goals, and function effectively in society

Social health – ability to make and maintain acceptable interactions

with other people E.g To feel sad when somebody close to you passes away

The absence of health is denoted by such terms as disease, illness and sickness, which usually mean the same thing though social scientists give them different meaning to each

Disease is the existence of some pathology or abnormality of the

body, which is capable of detection using, accepted investigation methods

Illness is the subjective state of a person who feels aware of not

At the time of Alma Ata declaration of Primary Health Care in 1978, health education was put as one of the components of PHC and it was recognized as a fundamental tool to the attainment of health for all Adopting this declaration, Ethiopia utilizes health education as a primary means of prevention of diseases and promotion of health In

view of this, the national health policy and Health Sector Development Program of Ethiopia have identified health education as

a major component of program services

Definition

Health education has been defined in many ways by different authors and experts Lawrence Green defined it as “a combination of learning experiences designed to facilitate voluntary actions conducive to health.”

The terms “combination, designed, facilitate and voluntary action” have significant implications in this definition

Combination: emphasizes the importance of matching the multiple

determinants of behavior with multiple learning experiences or educational interventions

Designed: distinguishes health education from incidental learning

experiences as systematically planned activity

Facilitate means create favorable conditions for action

Voluntary action means behavioral measures are undertaken by an

individual, group or community to achieve an intended health effect with out the use of force, i.e., with full understanding and acceptance

of purposes

Most people use the term health education and health promotion

interchangeably However, health promotion is defined as a

combination of educational and environmental supports for actions and conditions of living conducive to health

Various terms used for communication and health education activities

Information, Education and Communication (IEC) is a term

originally from family planning and more recently HIV/AIDS control program in developing countries It is increasingly being used as a general term for communication activities to promote health

• Information: A collection of useful briefs or detailed

ideas, processes, data and theories that can be used for a certain period of time

• Education: A complex and planned learning

experiences that aims to bring about changes in cognitive (knowledge), affective (attitude, belief, value) and psychomotor (skill) domains of behavior

• Communication: the process of sharing ideas,

information, knowledge, and experience among people using different channels

Social mobilization is a term used to describe a campaign approach

combining mass media and working with community groups and organizations

Health extension is an approach of promoting change through

demonstration, working with opinion leaders and community based educational activities

Nutrition education is education directed at the promotion of nutrition

and covers choice of food, food-preparation and storage of food

Family Life Education refers to education of young people in a range

of topics that include family planning, child rearing and childcare and

responsible parenthood

Patient education is a term for education in hospital and clinic settings

linked to following of treatment procedures, medication, and home care and rehabilitation procedures

Behavior Change Communication (BCC): Is an interactive process aimed at changing individual and social behavior, using targeted, specific messages and different communication approaches, which are linked to services for effective outcomes

Advocacy: refers to communication strategies focusing on policy

makers, community leaders and opinion leaders to gain commitment and support It is an appeal for a higher-level commitment, involvement and participation in fulfilling a set program agenda

Aims and principles of health education

Aims

• Motivating people to adopt health-promoting behaviors by providing appropriate knowledge and helping to develop positive attitude

• Helping people to make decisions about their health and acquire the necessary confidence and skills to put their decisions into

practice

Basic Principles

• All health education should be need based Therefore before involving any individual, group or the community in health education with a particular purpose or for a program the need should be ascertained It has to be also specific and relevant

to the problems and available solutions

• Health education aims at change of behavior Therefore multidisciplinary approach is necessary for understanding of human behavior as well as for effective teaching process

• It is necessary to have a free flow of communication The way communication is particularly of importance in health

two-education to help in getting proper feedback and get doubt cleared

• The health educator has to adjust his talk and action to suit the group for whom he has to give health education E.g when the health educator has to deal with illiterates and poor people, he has to get down to their level of conversation and human relationships so as to reduce any social distance

• Health Education should provide an opportunity for the clients

to go through the stages of identification of problems, planning, implementation and evaluation This is of special importance in the health education of the community where the identification of problems and planning, implementing and evaluating are to be done with full involvement of the community to make it the community’s own program

• Health Education is based on scientific findings and current knowledge Therefore a health educator should have recent scientific knowledge to provide health education

• The health educators have to make themselves acceptable They should realize that they are enablers and not teachers They have to win the confidence of clients

• The health educators should not only have correct information with them on all matters that they have to discuss but also should themselves practice what they profess Otherwise, they will not enjoy credibility

• It must be remembered that people are not absolutely without any information or ideas The health educators are not merely passing information but also give an opportunity for the clients

to analyze fresh ideas with old ideas, compare with past experience and take decisions that are found favorable and beneficial

• The grave danger with health education programs is the pumping of all bulk of information in one exposure or enthusiasm to give all possible information Since it is essentially a learning process, the process of education should

be done step-by-step and with due attention to the different principles of communication

• The health educator should use terms that can be immediately understood Highly scientific jargon should be avoided

• Health Education should start from the existing indigenous knowledge and efforts should aim at small changes in a graded fashion and not be too ambitious People will learn step by step and not everything together For every change of behavior, a

personal trail is required and therefore the health education should provide opportunities for trying out changed practices

Approaches to health education

• The persuasion approach –deliberate attempt to influence

the other persons to do what we want them to do (DIRECTIVE

APPROACH)

• The informed decision making approach-giving people

information, problem solving and decision making skills to

make decisions but leaving the actual choice to the people E.g family planning methods

Many health educators feel that instead of using persuasion it is better to work with communities to develop their problem solving skills and provide the information to help them make informed choices However in situations where there is serious threat such as an epidemic, and the actions needed are clear cut, it might be considered justified to persuade people to adopt specific behavior changes

Targets for health education

• Individuals such as clients of services, patients, healthy individuals

• Groups E.g groups of students in a class, youth club

• Community E.g people living in a village

Health education settings

When considering the range of health education interventions, they are usually described in relation to different settings Settings are used because interventions need to be planned in the light of the resources and organizational structures peculiar to each Thus, health education and promotion takes place, amongst other locations, in:

• Refugee camps …etc

Who is responsible for health education?

Health education is the duty of everyone engaged in health and community development activities Health Extension Workers are primarily responsible in working with the families and community at a grass root level to promote health and prevent disease through provision of health education If health and other workers are not practicing health education in their daily work, they are not doing their job correctly When treating someone with skin infection or malaria, a health worker should also educate the patient about the cause of the illness and teach preventive skills Drugs alone will not solve the

problems Without Health Education, the patient may fall sick again from the same disease Health workers must also realize that their own personal example serves to educate others

Role of health educator

• Talking to the people and listening of their problems

• Thinking of the behavior or action that could cause, cure and prevent these problems

• Finding reasons for people’s behaviors

• Helping people to see the reasons for their actions and health problems

• Asking people to give their own ideas for solving the problems

• Helping people to look as their ideas so that they could see which were the most useful and the simplest to put into practice

• Encouraging people to choose the idea best suited to their circumstances

Exercise

1 Define health and health education?

2 Explain why voluntary actions are so important in health education programs

3 List health education settings found in your locality

4 Mention five basic principles of health education

UNIT TWO Health And Human Behaviour

Objectives

At the end of this chapter, the trainees are expected to:

• Define behavior and related terms

• Describe the factors which affect human behavior

• Discuss on the role of human behavior in prevention of disease

and promotion of health

Introduction

In the previous section, we have tried to discuss the concept of health and health education Human behaviour is among the major determinants of the health of individuals, families or communities Healthy behaviours contribute to the overall health of individuals and communities and unhealthy behaviours adversely affect the quality of life people at different levels Most health issues cannot be dealt with

by treatment alone The promotion of health and prevention of diseases will usually involve some changes in life styles or human

behaviour

Definitions of behaviour and other related terms

Behaviour is an action that has a specific frequency, duration and

purpose whether conscious or unconscious It is what we “do” and how we “act” People stay healthy or become ill, often as a result of their own action or behaviour The following are examples of how people’s actions can affect their health:

• Using mosquito nets and insect sprays helps to keep mosquito away

• Feeding children with bottle put them at risk of diarrhoea

• Defecating in an open field will lead to parasitic infection

• Unsafe sex predisposes people to unwanted pregnancy,

HIV/AIDS and other STDs

In health education it is very important to be able to identify the practices that cause, cure, or prevent a problem

The words actions, practices and behaviours are different words of

the same thing

Life style: refers to the collection of behaviours that make up a

person’s way of life-including diet, clothing, family life, housing and work

Customs: It represents the group behaviour It is the pattern of action

shared by some or all members of the society

Traditions: are behaviours that have been carried out for a long time and handed down from parents to children

Culture: is the whole complex of knowledge, attitude, norms, beliefs,

values, habits, customs, traditions and any other capabilities and skills acquired by man as a member of society

Distinguishing characteristics of culture

• Culture is symbolic It is an abstract way of referring to, and understanding ideas, objects, feelings or behavior – the ability to communicate with symbols using language

To convey new ideas people may invent single words to represent many different ideas, feelings or values

• Culture is shared People in the same society share common behavior patterns and ways of thinking through culture For example people living in a society share the same language, dress in similar styles, eat much of the same food and celebrate many of the same holidays

• Culture is learned A person must learn culture from other people in a society For instance, people must learn to speak and understand a language and to abide by the rules of a society

• Culture is adaptive People use culture to adjust flexibly and quickly to changes in the world around them For instance a person can adjust his diet when he changes an area of residence

Examples of behaviours promoting health and preventing diseases

Healthy behaviours: - actions that healthy people undertake to keep

themselves or others healthy and prevent disease Good nutrition, breast feeding, reduction of health damaging behaviours like smoking are examples of healthy behaviours

Utilization behaviour: - utilization of health services such as

antenatal care, child health, immunization, family planning…etc

Illness behaviour: - recognition of early symptoms and prompt

self-referral for treatment

Compliance behaviours: - following a course of prescribed drugs

such as for tuberculosis

Rehabilitation behaviours: - what people need to do after a serious

illness to prevent further disability

Community action: - actions by individuals and groups to change

and improve their surroundings to meet special needs

Factors affecting human behaviour

1 Predisposing factors: provide the rationale or motivation for the

behavior to occur Some of these are:

• Knowledge

• Belief

• Attitudes

• Values

E.g For an individual to use condom, he has to have knowledge about condom and develop positive attitude towards utilization of condom

• Knowledge is knowing things, objects, events, persons, situations and everything in the universe It is the collection

and storage of information or experience It often comes from experience We also gain knowledge through information provided by teachers, parents, friends, books, newspapers, etc…

E.g knowledge about methods of prevention of HIV

• Belief is a conviction that a phenomenon or object is true or

real Beliefs deal with people’s understanding of themselves and their environment People usually do not know whether what they believe is true or false They are usually derived from our parents, grandparents, and other people we respect Beliefs may be helpful, harmful or neutral If it is not certain that a belief is harmful, it is better to leave it alone

For example, a certain society may have the following beliefs:

• Holding materials made of iron by mothers during postpartum (Neutral)

• Diarrhea may end up with death (helpful)

• Measles can not be prevented by immunization (harmful)

• Attitudes are relatively constant feelings, predispositions or

set of beliefs directed towards an object, person or situation They are evaluative feelings and reflect our likes and dislikes They often come from our experiences or from those of people close to us They either attract us to things, or make wary of them

E.g w/o Almaz had fever and visited the nearby health center The staff on duty that day was very busy and shouted at her,

“Do you want us to waste our time for a mild fever? Come back when we are less busy.” She did not like being shouted at This experience gave her bad attitude toward the health staff This bad attitude could discourage her from attending the health center next time she is sick

• Values are broad ideas and widely held assumptions

regarding what are desirable, correct and good that most members of a society share Values are so general and abstract that they do not explicitly specify which behaviors are acceptable and which are not Instead, values provide us with criteria and conceptions by which we evaluate people, objects and events as their relative worth, merit, beauty or morality E.g being married and having many children are highly

valued in most Ethiopian community

• Norms are social rules that specify appropriate and

inappropriate behavior in given situations They tell us what

we should and must do as well as what we should not and must not do

For Example,

• We often regard greeting as a social norm to be conformed among members who know each other

• Murder, theft and rape often bring strong disapproval

2 Enabling factors: these are characteristics of the environment

that

facilitates healthy behavior and any skill or resource required

to attain the behavior Enabling factors are required for a motivation to be realized

Examples of enabling factors include:

• Availability and or accessibility of health resources

• Government laws, priority and commitment to health

• Presence of health related skills

E.g Enabling factors for a mother to give oral rehydration solution to her child with diarrhea would be:

• Time, container, salt, sugar

• Knowledge on how to prepare and administer it

In general, it is believed that enabling factors should be available for

an individual or community to perform intended behavior

Behavioral intention Behavioral change

Enabling factors (Time, money and materials, skills, accessibility to health services)

Behavioral intention is willingness/ readiness to perform a certain behavior provided that enabling factors are readily available

3 Reinforcing factors: these factors come subsequent to the behavior

They are important for persistence or repetition of the behavior The most important reinforcing factors for a behavior to occur or avoid include:

significant influence to change others In the case of a young child, it

is usually the parents who have the most influence As a child grows older, friends become important and a young person can feel a powerful pressure to conform to the peer group

E.g a young man starts smoking because his friends encouraged him

Healthy person Early signs Disease Death

Fig 2.1 Levels of prevention of disease

Primary prevention

Secondary prevention

Tertiary prevention

Primary prevention

Primary prevention is comprised of those activities carried out to keep people healthy and prevent them from getting disease Examples of important behaviors for primary prevention includes using rubber gloves when there is a potential for the spread of disease, immunizing against specific diseases, exercise, and brushing teeth And any health education or promotion program aimed specifically at prevention of the onset of illness or health problems is also an

example of primary prevention

Secondary prevention

Secondary prevention includes preventive measures that lead to an early diagnosis and prompt treatment of a problem before it becomes serious It is important to ensure that the community can recognize early signs of disease and go for treatment before the disease become serious Health problems like tuberculosis can be cured if the diseases is detected at an early stage The actions people take before consulting a health worker, including recognition of symptoms, taking home remedies (‘self-medication’), consulting family and healers are called illness behaviors Illness behaviors are important

examples of behaviors for secondary prevention

Tertiary prevention

Tertiary prevention seeks to limit disability or complication arising from an irreversible condition Even at this stage actions and behaviors of the patient are essential The use of disability aids and rehabilitation services help people from further deterioration and loss

of function For example, a diabetic patient should take strictly his/her daily insulin injection to prevent complications

Exercise

1 Identify helpful, neutral and harmful beliefs in your locality

2 Discuss the enabling factors for latrine construction by a family, and contraception use by a woman

3 Give examples of important human behaviors, which contribute to primary, secondary and tertiary prevention of diseases

UNIT THREE Working With Communities

• Describe the benefits of community participation in the achievement of health education programs

• Explore the mechanisms of achieving community mobilization for common goal and the role of community leaders towards such an endeavor

Introduction

In the past, health education follows persuasion approach to force behavior change among individuals However, contemporary health education program underscores an informed decision-making approach emphasizing community participation and empowerment When the idea of primary health care was launched, community participation was one of the important principles identified for its implementation Although everyone talks about it, real community participation is rarely practiced

What is community?

Community could be defined as organized groups of people who

share a sense of belonging, beliefs, norms, and leadership and who usually interact within a defined geographical area

E.g People living in a “Kebele” or Woreda”

People organized under one religion etc

The concept of community participation

The health of the community will improve only if the people themselves become involved in planning, implementing, and having a say about their own health and health care Nevertheless,

involvement will not just happen

Many people emphasize the importance of community participation for any development issues, including health promotion, to become a success However, the question is how serious are we about involving individuals, families, and communities? Are we prepared - mentally and professionally – to listen to their concerns, to learn from them what they feel is important, to share with them appropriate information, to encourage and support them? Are we ready to assist them in choosing from alternative solutions, in setting their own targets and evaluating their own efforts? In many cases, so far, the answer is “NO”

In health education, we are concerned about how people actually feel, not how we think they should feel We are interested in how people look at their own problems, not only in the problems we see ourselves We want people to develop the confidence and skills to help themselves

The traditional approach in planning health care or health education program involves the decision to be made by experts This approach

is sometimes called the ‘top-down’ approach and contrasted with the

‘bottom-up’ approach where members of the community make the decisions In this model people are just told what to do We make decisions and expect them to follow

The concept of community participation or involvement encompasses the process by which individuals and families assume responsibility for the community and develop the capacity to contribute to their health and the community’s development It is a means by which the emphasis is on strengthening the capacity of communities to determine their own needs and take appropriate action Communities should not be passive recipients of services

The following are examples of actions that does not indicate genuine participation

• Involvement of individuals from the community in responding to health assessment survey questionnaires,